Provider Demographics
NPI:1962060236
Name:CARR, MICHAEL GLENNON (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLENNON
Last Name:CARR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10050 WOOD WIND CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5325
Mailing Address - Country:US
Mailing Address - Phone:502-822-0472
Mailing Address - Fax:
Practice Address - Street 1:317 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-4109
Practice Address - Country:US
Practice Address - Phone:502-822-0472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY010236OtherKENTUCKY BOARD OF PHARAMCY